Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5059

2. Registrant Information.

Registrant Reference Number: c

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc

Address: 450-1st Street S.W., Suite 2100

City: Calgary

Prov / State: AB

Country: Canada

Postal Code: T2P 5H1

3. Select the appropriate subform(s) for the incident.

Human

Packaging Failure

4. Date registrant was first informed of the incident.

06-JUN-07

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

05-JUN-07

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 14879      PMRA Submission No.       EPA Registration No.

Product Name: Lorsban 4E (Canada)

• Active Ingredient(s)
  • CHLORPYRIFOS

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Tingling skin

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

6/6/2007 About 40 hours ago, caller was handling a box with some containers of Lorsban inside. He didn't realize that a couple of the jugs inside were leaking. He thinks that the leaked from around the closure but he is not sure. He got some of the pesticide on his pants but didn't realize it at the time. He used the Lorsban up that was in the jugs then came in to shower when he noticed that a small area on his leg was tingling. He took a shower and the tingling went away quickly. Follow-up on 6/11/2007 Patient confirms that he remained symptom free and experienced no other problems after taking a shower.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Bottle-plastic / Bouteille-plastique

2. Did packaging failure occur during?

Transportation

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

6/6/2007 About 40 hours ago, caller was handling a box with some containers of Lorsban inside. He didn't realize that a couple of the jugs inside were leaking. He thinks that the leaked from around the closure but he is not sure. He got some of the pesticide on his pants but didn't realize it at the time. He used the Lorsban up that was in the jugs then came in to shower when he noticed that a small area on his leg was tingling. He took a shower and the tingling went away quickly. Follow-up on 6/11/2007 Patient confirms that he remained symptom free and experienced no other problems after taking a shower.

For Registrant use only

5. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.